Bilateral Scalp Necrosis in Giant Cell Arteritis

Abstract

Giant cell arteritis (GCA) is a medium-to-large vessel vasculitis of the elderly. Common constitutional clinical features include headache, scalp tenderness, and jaw claudication. Severe unilateral or bilateral visual loss is the most feared ophthalmic complication of GCA. Scalp necrosis is a known ischemic complication of GCA with approximately 100 cases reported in the literature to date. We report a case of scalp pain and an erythematous cutaneous lesion in the distribution of ophthalmic division of the trigeminal nerve that mimicked herpes zoster ophthalmicus. A temporal artery biopsy was positive for GCA, and small vessel arteritis was seen at the time of simultaneous skin biopsy. To the best of our knowledge, this is the first such report in the English language ophthalmic literature.

Scalp Necrosis Revealing Severe Giant-Cell Arteritis

“…Scalp necrosis is a dramatic but an outstanding complication of GCA. Apart from leading to infection, pain, and prolonged healing wound, scalp necrosis associated with GCA is considered as a prognostic factor for higher mortality and major morbidity [1]. Its onset tends to be insidious over weeks to months and abrupt in up to 20% of patients [2].…”

The pupillary dark reflex in acute disorders of consciousness

“…2 Unlike the pupillary light re ex, the much lesser-known pupillary dark re ex involves pupil dilation in response to darkness and predominantly re ects sympathetic pathways. [3][4][5] The latter pathways include the hypothalamus and cervical sympathetic chain and are modulated by input from cortical brain areas. Psychosensory stimuli like sudden noise or squeezing the back of the neck may enhance the pupillary dark re ex.…”

“…Psychosensory stimuli like sudden noise or squeezing the back of the neck may enhance the pupillary dark re ex. 5 Fig. 1 provides an overview of the anatomical pathways of the pupillary light and the pupillary dark re exes.…”

“…Disruptions to the pupillary dark re ex can occur with lesions that affect the sympathetic nervous system, even when the pupillary light re ex remains intact. 3,[5][6][7] Because acute brain injury often involves diffuse damage to multiple neural circuits, the pupillary dark re ex may provide additional information about autonomic and higher-order brain functions after brain injury compared to the pupillary light re ex. 8-10 However, unlike the latter, the pupillary dark re ex is not clinical routine in the intensive care unit (ICU).…”